How to Code for Kyphosis Using ICD-10 Codes

by | Published on Dec 24, 2019 | Medical Coding

Code for Kyphosis Using ICD 10 Codes
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Kyphosis refers to a condition in which the spine in the upper back has an excessive curvature. Also known as round back or hunchback, this spinal disorder can occur in any age, but is most common in adolescence or young adulthood. Having a small curve in the upper back area is normal. However, having a curve of more than 45 degrees is considered excessive that can cause discomfort and other issues throughout the body. In most cases, kyphosis causes few problems and does not require any specific treatment. Treatment for the condition depends on the patient’s age, and the cause and effects of the curvature. Patients may need to wear a back brace or perform exercises in order to strengthen the spine and adjust their posture. In severe cases kyphosis can be painful and cause significant spinal deformity and lead to breathing problems. Surgery may be needed in such severe cases in order to reduce the excessive spinal curvature. Physician practices need to use the correct ICD-10 codes to report this spinal condition. Relying on the services of a reputable orthopedics medical billing and coding company can help in accurate and timely claim submission for appropriate reimbursement.

The natural curvature of the spine is important for balance and helps people stand upright. However, if any one of the curves becomes too large or too small, it becomes difficult to stand up straight which in turn may affect your posture. Kyphosis occurs when the vertebrae in the upper part of the back called the “thoracic region”, become wedge-shaped. This causes the spine to curve forward more than usual. The common causes associated with the condition include – poor posture, developmental issues, disk degeneration, spinal injury, older age and abnormal vertebrae shape. If left untreated, kyphosis can cause severe damage to the spine and other areas of the body.

Types of Kyphosis

There are three different types of kyphosis and these include –

  • Postural Kyphosis – Regarded as one of the most common types of kyphosis, this occurs due to poor posture or slouching, but is not associated with severe structural abnormalities of the spine. This condition which usually becomes noticeable during adolescence is more common in girls than boys. The curve caused by postural kyphosis is typically round and smooth and can often be corrected by the patient when he or she is asked to “stand up straight.”
  • Scheuermann’s Kyphosis – Often common during the teen years, this type is caused by structural abnormality and usually affects the thoracic spine, but occasionally develops in the lumbar (lower) spine. It can lead to significantly more severe deformity – particularly in thin patients. The spinal condition is more common in boys than girls and stops progressing once growing is complete.
  • Congenital Kyphosis – As the name suggests, this type of spinal curvature is present at birth. The condition occurs when the spinal column fails to develop normally while the baby is in the uterus. Typically, congenital kyphosis worsens as the child ages. Such patients often require surgical treatment at a very young age to stop the progression of the curve.

Signs and Symptoms

Mild kyphosis may not produce any visible noticeable signs or symptoms. The signs and symptoms of kyphosis vary, depending upon the cause and severity of the curve. Common symptoms include –

  • A visible hump on the back
  • Tight hamstrings (the muscles in the back of the thigh)
  • Spine stiffness
  • Rounded shoulders
  • Back pain
  • Fatigue

In rare cases, progressive curves may lead to – weakness, numbness, or tingling in the legs, loss of sensation and shortness of breath or other breathing difficulties. If left untreated, this, condition can lead to several severe complications like – limited physical functions, digestive problems and body image issues.

Diagnosing Kyphosis – What Are the Treatment Options?

Physicians will begin diagnosis of kyphosis by conducting a detailed physical examination and previous medical history review. Patients will be asked to bend forward from the waist in order to view the spine from sideways. They may be asked to do several exercises or stretches to assess how the condition affects their balance and range of motion. Neurological examination will be performed to check the extent of reflexes and muscle strength. Other tests like X-rays, MRI (to look at the structure of the vertebrae) and bone density tests may also be performed as part of the diagnosis.

Treatment options for this condition depend on the cause and severity of the condition. Treatment will mainly focus on preventing the curve from worsening and restoring normal posture where possible. Non-surgical treatment options include physical therapy, non-steroidal anti-inflammatory drugs and wearing spinal braces. Physical therapy helps strengthen the back and abdominal muscles, relieve pressure on the spine, improve posture and reduce discomfort.

Physicians may recommend surgical treatment to those patients who suffer from severe forms of kyphosis that is pinching the spinal cord or nerve roots. Spinal fusion is the most common surgical procedure done for reducing the degree of curvature. As part of the procedure, the surgeon inserts pieces of bone between the vertebrae and then fastens the vertebrae together with metal rods and screws until the spine heals together in a corrected position.

Orthopedics medical billing and coding involves using the specific ICD-10 diagnosis codes to report various spinal conditions such as kyphosis on the medical claims that providers submit to health insurers. Orthopedists or other spinal specialists who treat patients need to submit accurate documentation that meets payer guidelines. Therefore, in addition to medical billing and coding services, insurance verification and pre-authorization services are crucial to verify the patient’s coverage.

ICD-10 Codes to Use

  • M40 – Kyphosis and lordosis
  • M40.0 – Postural kyphosis
    • M40.00 – Postural kyphosis, site unspecified
    • M40.03 – Postural kyphosis, cervicothoracic region
    • M40.04 – Postural kyphosis, thoracic region
    • M40.05 – Postural kyphosis, thoracolumbar region
  • M40.1 – Other secondary kyphosis
    • M40.10 -Other secondary kyphosis, site unspecified
    • M40.12 -Other secondary kyphosis, cervical region
    • M40.13 -Other secondary kyphosis, cervicothoracic region
    • M40.14 -Other secondary kyphosis, thoracic region
    • M40.15 -Other secondary kyphosis, thoracolumbar region
  • M40.2 – Other and unspecified kyphosis
  • M40.20 – Unspecified kyphosis
    • M40.202 – Unspecified kyphosis, cervical region
    • M40.203 -Unspecified kyphosis, cervicothoracic region
    • M40.204 -Unspecified kyphosis, thoracic region
    • M40.205 -Unspecified kyphosis, thoracolumbar region
    • M40.209 -Unspecified kyphosis, site unspecified
  • M40.29 – Other kyphosis
    • M40.292 – Other kyphosis, cervical region
    • M40.293 -Other kyphosis, cervicothoracic region
    • M40.294 -Other kyphosis, thoracic region
    • M40.295 -Other kyphosis, thoracolumbar region
    • M40.299 -Other kyphosis, site unspecified

Kyphosis occurs when the upper back becomes hunched due to an abnormally curved spine. Maintaining good body posture and back health can help prevent this spinal condition in the long run. Other prevention tips include – doing regular body exercise, avoiding slouching, using orthopedic equipment when using a desk or computer, and using well-designed backpacks that spread the weight evenly across the back.

Medical billing and coding for spinal conditions can be challenging. For accurate and timely medical billing and claims submission, healthcare practices can outsource their medical coding tasks to a reliable physician billing company that provides the services of AAPC-certified coding specialists.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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